INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2017 through October 20, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Mountain Laurel Recovery Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure all counselors met the required 1 year experiential requirements prior to hiring in 2 of 4 counselors reviewed.Employee #3 was hired as a Bachelor's Degree level counselor on 01/16/2017 and was still in the position at the time of the inspection. Employee #3 only had 4 months of clinical experience prior to hiring documented in the personnel record.Employee #7 was hired as a Bachelor's Degree level counselor on 10/16/2016 and was still in the position at the time of the inspection. Employee #7 did not have any documented clinical experience prior to hiring in the personnel record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Revised HR procedures regarding hiring of Clinicians to ensure that they have one year clinical experience prior to start. Clinical Director will be responsible for verifying all educational and clinical work experience and it will be documented accordingly in their pre-employment packet. The clinicians in mention are now meeting the requirement as they both have Bachelors degrees in Psychology and have one year direct clinical work experience, supervised by a certified Master's level clinician. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to provide documentation that an individual training plan for Employee #1, hired as the project director on 7/12/2015, was completed for the 2016 training year and the 2017 training year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will ensure compliance with all required documented elements of employee personnel files via program dashboard reports and HR file audits. The dashboard indictors track annual required training, worker compensation, recruitment, staff turnover, staff evaluation, orientation, and licensure verification / renewal of all employees. The results will be audited by the HR manager and reported quarterly to the Committee of the Whole and the Board of Governors. The Human Resource Manager will be responsible for monitoring compliance and notification to staff and supervisors one month prior to any deficiencies in the personal file. As well, following the DDAP inspection a change in leadership occurred at MLRC. Upon submission and acceptance of the plan of correction a change in project director will be submitted to DDAP listing the Executive Director as project manager. The above measures will ensure the project director completes all required annual trainings and performance evaluations. Oversight will be conducted by the HR manager thru the program dashboard reports. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in Employee #1's personnel record.Employee #1 was hired as a the project director on 7/12/2015 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from 01/01/2016 through 12/31/2016. Employee #1's record did not provide documentation of any trainings completeed for the training year reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will ensure compliance with all required documented elements of employee personnel files via program dashboard reports and HR file audits. The dashboard indictors track annual training requirements, worker compensation, recruitment, staff turnover, staff evaluation, orientation, and licensure verification / renewal. The results will be audited by the HR manager and reported quarterly to the Committee of the Whole and the Board of Governors. The Human Resource Manager will be responsible for monitoring compliance and notification to staff and supervisors one month prior to any deficiencies in the personal file. As well, following the DDAP inspection a change in leadership occurred at MLRC. Upon submission and acceptance of the plan of correction a change in project director will be submitted to DDAP listing Executive Director as project manager. The above measures will ensure the project director completes all required annual trainings and performance evaluations. Oversight will be conducted by the HR manager thru the program dashboard reports and reviewed by the Committee of the Whole. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of 8 personnel records, the facility failed to provide documentaton of an annual written individual staff performance evaluations in 1 personnel record.Employee #1 was hired as the project director on 7/12/2015. There was no documentation provided that the employee received an annual performance evaluation for the 2016 calendar year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will ensure compliance with all required documented elements of employee personnel files via program dashboard reports and HR file audits. The dashboard indictors track annual required training, worker compensation, recruitment, staff turnover, annual staff evaluation, orientation, and licensure verification / renewal. The results will be audited by the HR manager and reported quarterly to the Committee of the Whole and the Board of Governors. The Human Resource Manager will be responsible for monitoring compliance and notification to staff and supervisors one month prior to any deficiencies in the personal file. As well, following the DDAP inspection a change in leadership occurred at MLRC. Upon submission and acceptance of the plan of correction a change in project director will be submitted to DDAP listing the Executive Director as project manager. The above measures will ensure the project director completes all required annual trainings and performance evaluations. Oversight will be conducted by the HR manager thru the program dashboard reports. |
709.63(a)(2) LICENSURE D & A support plan
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(2) Drug and alcohol support plan.
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Observations
Based on a review of 7 client records, the facility failed to provide a complete client record, which is to include a drug and alcohol support plan in 2 of 5 applicable client records.Client #2 was admitted into the detoxification level of care on 09/12/2017 and was discharged on 09/09/14/2017. The client record did not contain documentation of a d&a support plan.Client #3 was admitted into the detoxification level of care on 09/28/2017 and was discharged on 09/29/2017. The client record did not contain documentation of a d&a support plan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A medical care plan will be developed at time of admission for all residents at detoxification level of care. Chart audits will be completed monthly by Nursing Supervisor and Regional Director of Nursing to ensure compliance and reported to the Committee of a Whole. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of 6 client records, the facility failed to provide complete documentation and verification of the client's age prior to the administration of medication in client record #5, who was admitted into the detox level of care with medication on 04/19/2017 and was discharged on 04/23/2017.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admissions Department will ensure proper identifying documentation at the time of admission. If a client arrives without photo identification, an alert will be issued by admissions staff via email notifying Nursing Supervisor, Regional Director of Nursing, Clinical Director and Executive Director. Efforts will be made to obtain proper identification via the court system and/or family member and/or referring agents. If no identification is obtained, client will not be treated with narcotic medications. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of client records, the facility failed to provide documentation that the narcotic treatment physician made face-to-face contact with the client within the 24 hour timeframe set forth in DDAP's Licensing Alert 04-12 in 6 of 6 client records reviewed.Client #1 was admitted on 08/01/2017 and was discharged on 08/04/2017.Client #2 was admitted on 09/12/2017 and was discharged on 09/14/2017.Client #3 was admitted on 09/28/2017 and was discharged on 09/29/2017.Client #5 was admitted on 04/19/2017 and was discharged on 04/23/2017.Client #7 was admitted on 02/09/2017 and was discharged on 02/16/2017.Client #12 was admitted on 09/15/2017 and was still active at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon referral for detoxification level of care, client's admission date will be coordinated with the physicians' schedule to ensure face-to-face history and physicals are performed. Nursing Supervisor and Regional Director of Nursing will complete monthly audits and results will be reported at Committee of a Whole meetings. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of 6 client records, the facility failed to document an initial urinalysis screening prior to the administration of medication for client #2, whom was admitted on 09/12/2017 and was discharged on 09/14/2017.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Regional Director of Nursing will complete monthly audits to ensure that initial urinalysis results are being completed at time of all admissions and results will be reported in Committee of a Whole meetings. Additionally, Nursing Supervisor will ensure that all new nursing staff are educated in administering urinalysis at time of admissions. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of 10 client records, the facility failed to document preliminary treatment plans in 6 of 8 applicable client records.Client #8 was admitted into the residential level of care on 08/04/2017 and was still active at the time of the inspection.Client #11 was admitted into the residential level of care on 10/07/2017 and was still actice at the time of the inspection.Client #13 was admitted into the residential level of care on 07/18/2017 and was discharged on 09/09/2017.Client #14 was admitted into the residential level of care on 04/23/2017 and was discharged on 05/31/2017.Client #15 was admitted into the residential level of care on 06/21/2017 and was discharged on 07/17/2017.Client #16 was admitted into the residential level of care on 02/19/2017 and was discharged on 04/24/2017.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An initial treatment plan will be developed with the client at time of step down from detoxification level of care or time of admission to residential level of care. Chart audits will be completed monthly by Clinical Director to ensure completion and results will be reported to Committee of a Whole. |
709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on a review of 10 client records, the facility failed to provide a complete client record, which is to include case consultation notes and/or follow-up information in 5 client records.Client #13 was admitted into the residential level of care on 07/18/2017 and was discharged on 09/09/2017. The client record did not contain documentation of any case consultation notes and follow-up information.Client #14 was admitted into the residential level of care on 04/23/2017 and was discharged on 05/31/2017. The client record did not contain documentation of any case consultation notes.Client #15 was admitted into the residential level of care on 06/21/2017 and was discharged on 07/17/2017. The client record did not contain documentation of any case consultation notes and follow-up information.Client #16 was admitted into the residential level of care on 02/19/2017 and was discharged on 04/24/2017. The client record did not contain documentation of any case consultation notes.Client #17 was admitted into the residential level of care on 03/15/2017 and was discharged on 05/20/2017. The client record did not contain documentation of any case consultation notes.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Continuing Care Coordinator will complete follow up calls with all residents upon discharge. During scheduled supervisions, agenda items will include calls made, results of calls, and an explanation for any deficiencies by the Clinical Director. Our morning treatment team meetings have been revised to include case consultations for all residents on safety contracts, behavioral contracts/treatment agreements, upcoming discharges, and potential extensions in treatment. The case consultations are then documented into the electronic medical record. The Clinical Director will conduct chart audits and report compliancy to the Committee of the Whole. |